Machines in Motion

In recent years, bioethics has become a rather stale academic enterprise, in which either widely accepted formal principles are applied in tedious detail to progressively narrower questions regarding advances in medical technology, or else sanctimonious philosophers chide the uneducated masses for failing to see how irrational it is for them to continue to believe that anything medical science does is really morally wrong. Jeffrey Bishop, a physician and philosopher, has written a book that dramatically alters that landscape. The Anticipatory Corpse is interesting, provocative and important—one of the most novel contributions to the field of bioethics of the last several decades. Bishop has many illuminating new things to say about the ethics of medical care for the dying. In the process, he helps to explain why bioethics itself is in such a sad state.

Bishop takes his central thesis from the observation of the French philosopher Michel Foucault that medicine made a dramatic turn in the late 18th century. In a particularly striking chapter of his masterful book The Birth of the Clinic, entitled “Open Up a Few Corpses,” Fou-cault wryly observes that with the development of pathological anatomy, the primary subject of medicine, concerned as it is with the care of the living, paradoxically became the dead human body. What doctors began to see when they saw living patients, Foucault argues, was what could be seen only at autopsy. Bishop skillfully portrays how this conception has played itself out into the 21st century, focusing on how medicine cares for the dying.

Postmodern French philosophy is not easy reading. Bishop’s exposition of Foucault’s thought and its applicability to medicine is lucid and accurate. Anyone who has attempted to read Foucault but was unsure what it all meant will find Chapter One alone to be a worthwhile investment.

The author also cogently argues that the Western world (and hence, Western medicine) has abandoned Aristotelian-Thomistic metaphysics for what he calls “the metaphysics of efficient causation.” What he means by this is that Aristotle’s old notion of the “four causes” of things—material, formal, efficient and final (Bishop calls these “proximate” and “ultimate”)—has not so much been supplanted as restricted. Bishop observes that modern science (and modern thinking more generally) embraces only the material and the proximate causes of things. As a result the “real” world is therefore seen to subsist only in matter and motion (the material and proximate causes). What have been drained from our conception of reality, however, are meaning and purpose (the formal and the ultimate causes).

The conclusion is that reality has no meaning or purpose and therefore no longer even requires an argument because the concepts of meaning and purpose simply are not admitted to the structures by which we reason. The formal and the ultimate causes are “hidden” from our view. Moreover, Bishop argues, this metaphysical viewpoint of efficient causation presents itself as an alternative to metaphysics—an anti-metaphysics, so to speak. Its very status as a particular metaphysical viewpoint is thus also hidden from our view. Efficient causation simply presents itself as unvarnished rationality.

Bishop shows how this metaphysical standpoint is nowhere more dominant than it is in medicine. In particular, he shows how deeply it has affected the way we now view death and the care of the dying. “Life,” says the French physiologist Bichat, “is the sum of the forces by which death is resisted.” Life, in other words, is dead matter set in motion by the forces of efficient causation. If this all sounds eerily like a description of the modern intensive care unit, then Bishop has made his point. This is how doctors think.

Once this metaphysics is coupled with the politics of population statistics, and once the king (who previously alone could exert dominion over life and death) has been deposed, Bishop argues that only two forces remain to fight for control over life and death: the modern state and the sovereign self. Each fights it out at the bedside, wielding the efficient causation of political power to determine whether the lifeless matter of the body continues in motion or dies.

Bishop goes on to argue that this metaphysics plays itself out in our notions of life and death. He shows how standard bioethical discourse about the care for the dying is rooted in the ethics of efficient causation. He argues quite cogently that such thinking afflicts the “pro-life” and pro-euthanasia movements equally, inasmuch as both regard life as mere matter in motion. Proponents of euthanasia, Bishop argues, assume that the dead matter of the body has a purpose only if assigned one by the sovereign self, and if the sovereign self no longer sees meaning or purpose there no longer remains a political reason to sustain the forces by which death is resisted. The pro-life movement, similarly, sees only matter in motion (bare life) and mounts a political campaign to sustain the forces by which death is resisted because bare life is the only value they can see from within the metaphysics of efficient causation.

Brain death, Bishop argues, arises because just as disease had to be located in the corpse, so death had to be located in a part of the body. Organ donation and transplantation devolve from the medical politics of the state’s utilitarian purposes. Even what seem to be reform movements in medicine are suspect. Palliative care is really a “violent” political movement exerting control over all aspects of dying, advancing the cause of “totalizing” medicine. Professional hospital chaplains are also suspect, submitting even the spiritual to the measurement techniques and politics of biomedical statistical thinking.

The Anticipatory Corpse is striking and original. One wonders, however, if Bishop might not have been better served if he had regarded his central idea as one among many threads partially explaining the malaise of modern medicine. By attempting to bring everything under his thesis, he misses much that is really good about contemporary medicine. His own view is “totalizing” and thus, at times, overwrought. The book is decidedly negative and his concluding chapter, gesturing toward a new view of medicine, falls flat.

Nonetheless, his main thesis is so novel and so interesting and explains so much about modern medical care for the dying that it should be required reading for anyone interested in bioethics.

Daniel P. Sulmasy, M.D., is the Kilbride-Clinton Professor of Medicine in the department of medicine and the Divinity School of the University of Chicago.

Dr. Sulmasy writes, "Professional hospital chaplains are also suspect, submitting even the spiritual to the measurement techniques and politics of biomedical statistical thinking." As a hospice Chaplain, I wouldn't necessarily think of myself as "suspect;" rather, I see my own discipline as being subjected to what has been called the "medical model" of viewing a patient and coming up wanting in that regard. It seems to me that, in a finally vain attempt to remain relevant to the modern health care machine-and therefore worthy of continued funding-some spiritual care providers have attempted to achieve legitimacy by adopting the language and approach discussed by Foucault. One sees that reflected in the way that, up until recently, our patients were often introduced to the interdisciplinary group by naming their problems, e.g., "Mr. X presents with Stage 4 lung cancer with metastases to the bone. His problems are pain, GI, GU, etc." At the end of the physiological overview, the Social Worker and/or Chaplain might be asked, "Do you have anything to add?" as if "spiritual" were yet one more problem rather than seeing Mr. X first as a person with a life made up of goals, opportunities and challenges rather than the sum of his medical maladies. (Dr. Ira Byock has written and spoken on this subject previously.) Thankfully (and at least at our facility), we have now reversed this order of presentation. Our Social Worker introduces the patient as a person in her own world, and the medical information is focused on the efficacy of our attempts-medical, social, emotional, spiritual, etc.-to provide the patient with the highest quality of life available to her at this time. Perhaps this is a start in reversing the reductionistic approach that too often seems to be governing our thinking in the care of our chronically- and terminally-ill sisters and brothers.